Application for Pet Assistance

The below application are for qualified individuals and families who need assistance with food and regular vet care visits including vaccinations, rabies, spay and neutering. Please complete the below information and provide copies of items requested. Please read the terms and sign prior to your submission.

First and Last Name:
Street Address:
City, State, Zip Code:
Day Phone:
Evening Phone:
e-mail
Describe what assistance you are requesting:
Please provide a description of your pet (breed, sex, age, special needs and any other information that will help us make a determination for assistance:

Please provide copies of the following documents with your application:

  1. State of Florida Identification with photo.
  2. Proof of current public assistance such as:
  3. Food Assistance Eligibility
  4. Medicaid Card
  5. If you are not currently on any public assistance program please provide:
  6. Last 3 months proof of income
  7. Copy of previous year tax return.
  8. Provide proof of dog ownership for pet(s) needing assistance:
  9. Rabies Certificate or Letter from veterinarian.
  10. Proof of Spay or Neuter

TERMS OF SERVICE

Terms and Conditions

This agreement is between Destiny for Dogs, Inc. (DFD) and the applicant. Destiny for Dogs, Inc. was formed to supply food and basic medical care for individuals and families who would not be able to feed their pet and provide the basic medical needs of their pets without assistance. Destiny for Dogs, Inc. intends on accomplishing keeping beloved pets with their families who provide love and add strength to the family instead of having these pets dropped off at kill animal shelters where they most likely would be put to sleep. By supplying food and basic vet care we are removing the choice of sometimes one feeding their pets before themselves. This assistance is accomplished by receiving donations and grants from individuals and organizations. With Destiny for Dogs assistance we hope to relieve the burden on animal shelters of having so many animals to care for.

Indemnification

You agree to indemnify, defend and hold harmless Destiny for Dogs, Inc., its officers, directors, employees, agents and third parties, for any losses, costs, liabilities and expenses (including reasonable attorney’s fees) relating to or arising out of your use of our services being provided.

I / We hereby authorize Destiny for Dogs, Inc. to have access to all medical records for our pet(s) from any and all Veterinarians that we have used currently and in the past. This information will be used to help determine the approval of assistance.

I / We hereby confirm that all information provided in and with this application is true and correct. I understand that Destiny for Dogs, Inc. at its sole discretion can approve or deny this application and will accept any decision as the final determination.

Signature of Applicant #1Signature of Application #2

Print Name and DatePrint Name and Date

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